Client Form

Are you wondering what it’s like to be hypnotized? How can hypnosis help you? Do you want to lose weight, sleep better, reduce stress or break a habit? You have come to the right place.

Before you first session, please fill out these forms and read disclaimers. Thank You!

The undersigned Client acknowledges that he or she has been informed of the following information:

Hypnotherapist agrees to provide professional services in accordance with acquired training and experience giving undivided attention during scheduled consultations to facilitate Client’s benefits. Hypnotherapist’s work is Client-centered. Services provided utilize induction of hypnosis, and methods and principles to help clients discover their inner creative abilities in order to develop positive thinking and feeling and to transform undesirable habits and behavior patterns.

Therapeutic goals are to achieve freedom from restrictive thought and belief systems, to assist in solving personal problems, to develop motivation and achieve goals. Client may be taught the use of self-hypnotic techniques to assist in achieving goals and resolving issues that have been mutually agreed upon by Client and Hypnotherapist. Hypnosis is not a state of sleep, but is a natural state of mind that can produce extraordinary levels of relaxation of mind, body and emotions.

The principles and theories upon which hypnotherapy is based are accessing and utilizing the power of one’s inner resources. Hypnosis can transcend the critical analytic level of mind, and facilitate the acceptance of suggestions, directions and instructions desired by the Client. The hypnotherapist utilizes interviews, discussion and hypnotic methods dealing with underlying issues whenever appropriate, with the goal to achieve effective and lasting results.

Services to be provided do not include the practice of medicine, as Hypnotherapist is not a licensed physician. These services are non-diagnostic and are complementary to the healing arts services that are licensed by the state. The California State Legislature has determined that state licensing may not be conferred upon an occupational group for purposes of status or prestige.

The primary purpose of licensing laws for legally defined Healing Arts and Mental Health professionals is to protect public health and safety. Accordingly, Hypnotherapists are not issued licenses by any State Governmental Agency to engage in their professional services.

For complaints not resolved by the Hypnotherapist, contact the American Council of Hypnotist Examiners, 700 S. Central Ave., Glendale, CA 91204.

I, the undersigned Client acknowledge that I have been advised of the foregoing information, and that I have been given a copy of this “Client Information” form.

HYPNOSIS / HYPNOTHERAPY INFORMED CONSENT

I am over age 18, and consent to engage in the process of hypnosis/hypnotherapy and hypnosis education offered by Napa Hypnosis Center.

I understand that hypnosis/hypnotherapy can provide assistance in resolving problems that I present to my hypnotist/hypnotherapist, but that other solutions, including medical intervention, may also be of value or even required.

I agree to continue all medicines and medication as prescribed by my attending physicians, and understand that hypnosis/hypnotherapy is not a substitute for medical and/or psychological care.

If my symptoms progress, I agree to seek medical attention, and in the event of a medical emergency and/or if I feel suicidal, I will call 911 or other emergency help.

I understand that the methods of hypnosis and/or hypnotherapy include relaxation, deep breathing, creative visualization and other techniques of producing physical and emotional responses.

By agreeing to this process I am agreeing to:
1) Be guided into a state of hypnosis and/or self-hypnosis by a qualified professional hypnotist.
2) Receive education about the use of hypnosis, visualization exercises, breath-work, and positive suggestion.
3) That I understand that at all times I am in control of this process, that I can stop the process at any time to ask questions, clarify, to express my feelings and comfort level, and that at any time I may stop the process of learning therapeutic hypnosis education altogether.

By signing this statement, I acknowledge that if I am under the care of a physician or licensed mental health professional, he/she has been or will be made aware of my participation in hypnosis education and of my intention to use these techniques in my personal life.

I recognize my need to continue prescribed medical treatments and/or medication until advised by a licensed healthcare professional to the contrary.

I understand that my hypnotist’s role is limited to providing me with techniques designed to increase awareness, concentration and creativity, and to manage both the physical and emotional presence of stress at a non-medical level in life situations.

If at any time I feel the need for referral to a different hypnotist or to a licensed medical specialist I will make my thoughts known and I understand that a professional referral will be provided.

I have read and acknowledged disclaimers. Please insert you name below.

If you are human, leave this field blank.

First Name

Last Name

Street Address

City

State

Zip

Home Phone

Best Phone to Contact

Email

Marital Status

Date of Birth

Occupation

Emergency Contact

Phone

Who referred you to us? How did you hear about Napa Hypnosis?

What is your desired Outcome from this treatment?

How will your life look like or feel when this/these issues is/are resolved?

Doctor's Name, Address, Phone

Please list all conditions for which you are currently treated:

Current Medication (include Herbal and Vitamin Supplements)

Do you have religious or spiritual preferences that we should know about?